<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html dir="ltr" xmlns="http://www.w3.org/1999/xhtml">
<%@include file="/WEB-INF/taglibs/common/taglibs.jsp" %>

<head>
    <title><spring:message code="menu.taxpayer.paid"/></title>
    <meta content="text/html; charset=utf-8" http-equiv="Content-Type"/>
    <link rel="stylesheet" href="<c:url value="/css/styles.css"/>"/>
    <script src="<c:url value="/javascripts/common.js"/>" type="text/javascript"></script>
</head>

<body>
<div class="page">
    <%@include file="../top_menu.jsp" %>
    <table width=100%>
        <tr>
            <td><c:import url="/WEB-INF/jsp/menu/taxpayer_menu.jsp" /></td>
        </tr>
        <tr>
            <td>
                <%@include file="/WEB-INF/jsp/include/messages.jsp" %>
                <br/></td>
        </tr>
    </table>
    <div class="contentArea">
 <table>
            <tr>
                <td width="50%">
                    <table>
                        <tr>
                            <td colspan="2"><b>Tax Payer Info</b></td>
                        </tr>
                        <tr>
                            <td>SSN:</td>
                            <td><input type="text" name="ssn" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>First Name:</td>
                            <td><input type="text" name="firstName" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Middle Name:</td>
                            <td><input type="text" name="middleName" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Last Name:</td>
                            <td><input type="text" type="text" name="lastName" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Amount Expected:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Amount Received:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Transaction ID:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Batch ID:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Order ID:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
						<tr>
                            <td>Status:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>			
                    </table>
                </td>
                <td width="50%" valign="top">
                    <table>
                        <tr>
                            <td colspan="2"><b>Spouse Info</b></td>
                        </tr>
                        <tr>
                            <td>Spouse SSN:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Spouse First Name:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Spouse Middle Name:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Spouse Last Name:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Date:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Check Cleared Bank:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
                        <tr>
                            <td>Reference ID:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>                                                
                        <tr>
                            <td>Comments:</td>
                            <td><input type="text" size="30" maxlength="30"/></td>
                        </tr>
                        
                    </table>
                </td>
            </tr>
            <tr>
            	<td colspan="2"><b>Match Needed:</b></td>
            </tr>
             <tr>
            	<td colspan="2">
            		<table width="100%" border="0">
            			<tr>
            				<td>&nbsp;</td>
            				<td><b>Transaction ID</b></td>
            				<td><b>SSN</b></td>
            				<td><b>First Name</b></td>
            				<td><b>Last Name</b></td>
            			</tr>
            		</table>
            	</td>
            </tr>
            <tr>
                <td colspan="2" align="center"><input type="submit" value="Submit" name="step2"/></td>
            </tr>
        </table>
    </div>
</div>
<%@include file="/WEB-INF/jsp/include/footer.jsp" %>
</body>
</html>